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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - - -----------;-.�—_�.--�----�---- _ Permit No. <br /> t A (Complete in.Triplicate) <br /> s / <br /> ---------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made inn compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATI N ._f1.- a__--- - -- ---------------------- CENSUS TRACT -------------------------- <br /> -------------------- - ------- <br /> Owner's Name ------ ------- � Phone ' -." <br /> Address -------------� V ------5 3` J`i J'-- ---. Cit <br /> T Y // -- <br /> Contractor's Name = •------------=-=------ -License # -. �. Phone �El�-�- 6 f <br /> Installation will server Residence Apartment House-n-Commercial,❑Trailer Court -❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:-----'----- Number of bedrooms --;L'----Garbage Grinder ----- ------ Lot Size ----------------- <br /> Water Supply: Public System and name -------------------------------•---------------------------------------------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe '❑ .Fill Material ------------ If yes,type ------_-------_-__-_-_-- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK SizerLiquid Depth Ir <br /> CapacityType _f �`-'- ----------- - No. Compartments .._-.�'_-. <br /> -_._____ <br /> Distance to nearest: Well -__--_---5�- - ------------Foundation -:--l-U------------ Prop. Line ...... <br /> -V <br /> LEACHING LINE <br /> No. of Lines --------5------------ Length of/�each <br /> �line-------�J..4- __i.______ Total Length ---Z10--�_--_-----._ <br /> { _ 'D' Box --_-✓-.-- Type Filte_r,Material AB'04_ p s� <br /> -- -_----- __.De Depth Filter Material -;��------------------------------- <br /> Distance <br /> ------ --•--------------Distance to nearest: Well ----- ------ Foundation -----/D__`: --_•.Property Line -----.57.:1:`_'.-_--_ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -----------------!---------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ----- -------------------------- t-_=------Rock Size ---A-------------------..--.--. <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .--------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date._------------------------- ....... <br /> SepticTank (Specify Requirements) ----------------------------------------------------------- --------------------•--•---------------------- --_----------------------------- <br /> Disposal Field (Specify Requirements) -------------------------- ----------------------------------------------------•--------------- <br /> ----------------------------------------------------------------------------------------------------------------------' -----------------------------'-------`-------------------------------------- <br /> a. <br /> �1 <br /> ---------------------------------------------------------------------------------------------------------------`------------------------------------`----"------------------------------------------- <br /> (Draw existing and required addition on reverse—side).:i r <br /> I hereby certify that I have prepared this-application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- --- -------- r Owner <br /> - ----------- -------------------------------------- <br /> ` ----- -Title ----- ------------------------------- ------------- --- <br /> (If oth han owner) <br /> FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPf ED BY ------------------ <br /> --irlr - ' - --------------------------- --------------------------------------- DATE __ <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------- ---------------------------------------------DATE ------------ ------------------------------ <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------•------------------------ -----=--------------------------- <br /> ---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------ -------------------------------------------------------------------------- ---- ---- --- <br /> -----------------------------•----•---------_------- <br /> Final Inspection b ------------------Date --- _-- +R 7.r�_ --------------_--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />